Saturday, November 14, 2015

Initiating Milk Supply with a Pump

There are few feelings as helpless as having your child in the NICU.  It can make you feel like you are alone in the world and that you are unable to care or provide for your child. The one thing that you can have full control over is pumping breastmilk.  It provides a tangible outlet for your need to care and an invaluable source of nutrition and healing for your little one.

Twice now, I've had to initiate and maintain supply for my baby for their first several months of life.  My boy C and my Baby Girl both had complex medical situations that meant that we were not going to be able to breastfeed in the first few months of their lives.  I was absolutely committed to breastfeeding and did a lot of research into how to maximize my supply.  I've been answering a lot of questions on this topic and I wanted to take a moment to summarize what I've learned.  My experience is with Medela products and all pump based information will pertain to the Symphony/Pump In Style Advanced pumps, which I used for both of my children.  For exclusive pumping, a Symphony is your best bet for gaining and maintaining supply.

The very first thing you should do if you are reading this article is watch these two videos.  They are the key techniques for successfully initiating and maintaining your supply.

Hand Expression to initiate supply - This video will show you the technique for hand expression that I will refer to later on.  This technique is incredibly important especially during the first week.  Using this technique in the first week can increase your supply by 85%.

Hands on Pumping - Maximizing production by hands on pumping can make a huge difference.  I express almost nothing if I am not massaging while I pump.  If I massage while pumping I will express between 60-90 ml (2-3 oz) per side, without massage I will express approximately 15 ml (half an ounce) from each breast in the same time frame.

Initiating Supply

Your first goal when initiating milk supply with a pump is to pump for the first time within 6 hours of giving birth, if at all possible given your own health and well being.  Do not despair if you cannot achieve this.  Your health must come first, but if possible, at the very least, hand express in that time. For the first week, your goal must be to intensely focus on achieving your expression goals.

Goal 1: Pump 8 times a day for 15 minutes each time
Goal 2: Hand express colostrum 6 times each day in addition to pumping

The pumping goal is pretty straightforward and all NICU lactation teams will tell you establishing a solid pumping schedule will be the foundation of your supply.  I found it easiest to time my pumping to end just before my baby was next scheduled for care.  If, for example, my baby is scheduled for 3, 6, 9 and 12, I'd pump at 2, 5, 8 and 11.  This gave me time to setup, pump, clean up and take whatever I was able to get out down to the NICU in time to participate in my baby's care. It also meant that anything I'd just produced could be given fresh whenever possible.  While you are inpatient, I find this to be a great routine for helping ensure you can spend time with your baby while providing them the most important and sustaining element you can.

Initially, pumping will seem futile.  You'll get next to nothing out and if you've never done it before, you might feel pretty silly.  Keep at it.  That stimulation is critical for signalling to your body that the milk machine is online and needs to get rolling!  You may find that even if the colostrum does come out and gets down into the valves, you'll be unable to get to it.  That liquid gold will be sitting, just out of reach.  It is enough to make a hormonal woman cry... no seriously.. I cried.

That leads to part 2, hand expression.  This is your best bet for getting usable colostrum in the first 2-4 days.  Technique is everything when it comes to hand expression.  First, ask lactation or your Post Partum Nurse to provide you with syringes, caps and labels to store and identify your bounty.  Next, if you have a Medela Symphony starter kit provided by the hospital, find the 45 ml colostrum collection bottle that comes in that packet.  It is your new best friend.  The curved bottom makes colostrum collection with a syringe a snap as long as the colostrum makes it into the container.  If possible, have a second person help you with collecting the colostrum.  Hand expression of colostrum is MUCH easier with a second person doing the collection while you focus on expressing out the colostrum.  Colostrum is thick and drips out slowly, which makes getting it to the container without an extra set of hands a challenge.  Collection only takes a few minutes, ask your L&D nurse if they can help or if there is a CNA who can provide you with some quick assistance if you don't have someone with you.   Using the technique specified in the Hand Expression video above, express as much colostrum as you can.  I usually did this about an hour before I was scheduled to pump.  By day 2, I was getting several milliliters at a time.  I know this doesn't feel like much, but colostrum is incredibly nutrient dense and every drop makes a huge difference.  I always felt proud walking my meager offering down to the NICU.

Keep up the extra hand expression for the first 6 days.  Even if your milk comes in and you start getting good results with the pump.  The extra stimulation makes a huge difference for moms who are away from their babies.  The lactation consultants at Stanford who produced the hand expression video ran a study and found that women whose babies were in the NICU had an 85% greater supply if they hand expressed for the first 6 days.

I tracked my milk production every time I pumped or hand expressed.  Once my milk started coming in I found I gained about 30 ml (an ounce) per day before leveling out around 1100 ml /day.   Don't obsess over every milliliter, but tracking your total output can help identify supply issues before they become critical.

Maintaining Supply

The first 12 weeks are critical for establishing a supply that will last for the year(s) you will be breastfeeding.  Some people call your first 12 weeks post partum the 4th trimester.  Hormones are still raging and chemicals are driving a number of post partum processes including milk supply.  Because your supply is hormone driven at this point, you must be diligent about pumping 8-12 times per day.  One of the most important hormones for milk production is prolactin.  Prolactin levels peak overnight, which is why your morning pump usually produces the most milk.  The most important pump of the day occurs between 1 am and 5 am as your prolactin levels are peaking.  Pumping at that time is a huge part of signaling to your body that more milk is needed. I recently heard some amazing advice for a foolproof way to ensure you don't miss that middle of the night pump. Before you go to bed, drink a bunch of water. Then, when you wake up to pee, pump too. Brilliant!

Power pumping is a great technique for mimicking the growth spurts that your baby would use to increase your supply.  I usually power pumped once every 4 weeks for a week.  I power pumped at 9 at night.  My power pump sequence is pump 20 minutes, rest 10 minutes, pump 10 minutes, rest 10 minutes, pump 10 minutes, done.  This would help boost my supply back if it started to lag.

Once your hair begins to fall out... did no one tell you that would happen? Yeah.. it is totally a thing.  Anyway, once your hair begins to fall out, you can get a little less militant about pumping. You still need to pump at least 8 times per day.   One of those pumps must still be between 1 am and 5 am, but you can stretch a night pump to 4 hours instead of 3 and if you must shift another pump around every once in a while, it is less damaging than it was in the first 12 weeks.  You've finally shifted into supply and demand production instead of hormone based production.

Your goal should be 750 - 900 ml a day per baby, that is the average supply range needed to feed baby 100% breastmilk (fortified or not).  Sometimes you can have a HUGE supply up front and as your body gets closer to that 12 week mark, you start regulating down to a stable, maintainable supply.  It can be scary and frustrating to see your supply drop, however, it can be a good thing.  If you are planning to shift from pumping to breastfeeding, having your supply more closely match baby's needs will mean less problems with oversupply, fore/hind milk issues and forceful letdown once baby goes to breast.

Shield Fit and Pump Maintenance

Comfortable shields are a HUGE must when it comes to pumping.  There are several different shields available for the standard Medela pump kits and I have tried them all.  You can read more about correct shield fit on Medela's website, here

Standard Medela Sized Shields - available in small (21 mm), Medium (24 mm), Large (27 mm), XL (30 mm) and XXL (36 mm)
Medela Glass Shields (ok, I didn't try these, a lactation consultant mentioned them, but I've never seen them)
Pumpin' Pals - This set of 3 sizes gives you a lot of options. 

For me, 27 mm worked best.  I do not follow the rules on the Medela hand out.  My breasts get sucked down into the shields because my connective tissue is really loose. Play around with shields and figure out which ones work best for you.  If your baby is still inpatient, your lactation team may be able to provide you with alternate shield sizes as needed.  Check with them to make sure your pump is fitting you correctly.  A poorly fitting shield will dramatically affect supply.

The other areas to really watch on your pump are the yellow valves and white membranes.  If either of those crack or tear, suction will be lost and your pumping output will suffer.  I change out the membranes about once a month when pumping full time.  I always keep at least one extra set of yellow valves on hand as well.  When they crack it can be subtle, but there is no mistaking the sudden supply drop.

A quick note on letdown:  Letdown is a trained reflex.  At this point, the sound of a pump will start letdown for me.  Establishing a ritual or routine when pumping can help trigger letdown.  I always had ice water with me and would take 3 big swallows when I started pumping or when I cycled back to the initiation phase (which I did every 8 minutes for 3 letdowns total).

Tools and Accessories

When my daughter was unexpectedly born at 25 weeks, I was frantic to get a few supplies that I knew would make my life easier.  For those who aren't frequent blog readers, my son was born with a cardiac defect and I spent a lot of time pumping while inpatient.  I had a very clear idea of what I wanted with me as we climbed back onto the hospital roller coaster.

  • The Simple Wishes Hands Free Bra in Small-Large or L-Plus (I use L-Plus) I prefer the black to the pink.
  • The grasspad Drying Rack - Great for drying annoyingly shaped pump parts.  The flower holds a bunch of valves and I put the membranes in the cup of the flower.  Works very well. 
  • Extra Pump Parts - I cannot emphasize enough how much extra pump parts help.  You can put the set of pump parts you are using in the fridge and use them several times over before you wash them, but in the end, I find 3-4 sets of pump parts makes all the difference.  We were inpatient so much with my son that I ended up with about 20 sets.  I kept 2 at the hospital, 3 at work, 1 in the car in case of emergency and the rest were used at home.  I only washed pump parts once a day at home, even on the weekend when I'd pump 10 times.  It was great!
  • Coconut Oil - I put a little on the shield and a little on my nipple, friction is NOT your friend.  I like coconut oil because sometimes it is solid and easier to control ;)
  • Lanolin - after pumping, lanolin can be amazingly soothing.  I found the medela lanolin lovely and easy to spread, the other stuff I tried was much thicker and seemed to add to my pain as I tried to spread it.  I also use this as my first line of defense diaper rash cream. 
  • All Purpose Nipple Cream - If your nipples do become cracked, or get a yeast rash or are just miserable, Jack Newman's all purpose nipple cream is AMAZING.  Your OB has to prescribe it and you have to get it at a compounding pharmacy, but it is TOTALLY WORTH IT.
  • Steam Sanitizing Bags - living in the hospital makes me positively germ-phobic.  The steamer bags give me peace of mind.  We don't sterilize nearly as much once baby isn't fragile, but in those scary months where everything is looming and scary, I'm a super clean freak!

In case you need it (and I hope you never do) here is a link to my master hospital packing list.  I use this as a checklist when anyone in our family goes inpatient.

Fresh vs Frozen

When it comes to breastmilk, fresh is best.  Unless you are in the first two weeks post partum, in which case, colostrum, fresh or frozen is better than anything.  So, use up the entire supply of your first 2 weeks of milk, then start trying to get fresh milk to baby whenever possible.  Fresh milk will be more "alive" than its frozen counterpart.  You will also have fewer lipase issues with fresh milk (the fresher the better). I was able to supply my daughter's daily needs for fresh milk with 1-2 pumps a day.  The rest I froze and eventually donated as I was able to keep up with my daughter's long term needs.

Also, if you have to change bottles mid pump (we had 2 ounce bottles and I had one side that would do way more than that), the second set of bottles contain higher fat content hindmilk and you should mark them so they know to use them first.  Our NICU had special stickers used to mark hindmilk.  I would pump until both sides were about 1 ounce down and then I'd take one bottle off, replace it, take the other bottle off and combine it with the other and pump hind milk on both sides.


Galactagogues are foods or medicines that can increase your supply. Kellymom has a great article on galactagogues.  I've also written a fair bit over on an article I wrote several years ago.  Go here to read it or read on for a brief summary.  Drink water, LOTS of water.  Oatmeal = awesome.  Oatmeal increases prolactin.  Steel cut oats are best.  You can make steel cut oats in a crockpot, rice cooker or on the stove, but these days I use an instant pot which is all in one.  Eat oatmeal every day to increase your supply. You can also try lactation cookies.  Brewers yeast seems to be another great food to increase supply (though it tastes bitter, yay cookies and sugar for helping cover the taste).  You can branch into herbal remedies, I like Motherlove's product line a lot.  If you have serious supply issues, your doctor can prescribe medication.  I'd avoid Reglan, my research indicates it is prone to more serious side effects than domperidone.

Extra Milk

If you do end up with an overabundance of milk, you can donate the extra to help other NICU babies.  For those of us in North America, you want to find a member of the Human Milk Banking Association of North America.  These milk banks are non-profit and provide pasteurized human milk to the babies who need it most.  You can find other banks, but some of them are actually run by for profit companies such as Prolacta (Makers of human milk based human milk fortifier).  Those banks accept your milk and then turn around distill it to its components and sell it for a huge profit.  They do offer incentives such as donations to other charities, but for me, I'd rather donate to a HMBANA member bank.


Facebook has a support group for just about every condition or happening these days.  As a rule I've found these groups supportive and amazingly useful as I navigate these times.  Babycenter also has a number of helpful groups and La Leche League can also be a big help.  For general research and questions, Kelly Mom is incomparable and should be your first stop.

As of this writing, Baby Girl is 14 months old and still nursing about 6 times per day.  I breastfed my son until he was almost 3 years old, he stopped when my milk dried up during my previous pregnancy.

I hope this helps you on your journey.  Thanks for reading.

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